Ministry to Special Needs Assessment

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At Locust Valley Chapel our desire is that all people discover, develop, and demonstrate life with Jesus. As a result, we intentionally seek to give students affected by special needs and their families opportunities to worship and grow in relationship with Jesus.

Please Note: This form must be completed in one sitting. Please make sure you have at least 15 minutes to be able to complete the assesment. The information is only saved when you hit "submit". We respect your family's privacy and will only use the information for ministry purposes. We recognize that there may be situations that we are unable to accommodate.

 
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Mailing Address

 
 
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Caregiver

 
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Siblings Living at Home

 
 
 
 
 
 
 
 
Diagnosis and Special Needs: Profile of Child/Student affected by Disability. Please answer all that apply.

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Education

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Additional Support Services

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Allergies

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Social Behavior/Interests/Preferences

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CONSENT, RELEASE, & MEDICAL AUTHORIZATION / RELEASE OF LIABILITY FORM

Recognizing the risk associated with the operation of a ministry for individuals with a disability and the possibility of physical injury or loss, the below named parent/s of the above named individual hereby agree to the following during the duration of his/her participation in the program.
 
CONSENT, RELEASE, & MEDICAL AUTHORIZATION

1. Blanket Permission: I hereby grant permission for full participation in any or all of the activities/programs that are held on or off-site with Locust Valley Chapel, Coopersburg, PA (the “Church”) during the period commencing with the date of this form. 2. Release: I understand that the Church staff and adult supervisors will endeavor to provide individual care and safety for each participant in each activity and/or program. I am aware that neither the Church nor any member of its staff or adult supervisors can assume responsibility for any injury or damage, which may occur in connection with such program or activity. Therefore, by signing below I am agreeing to the Legal Release of Liability and the Indemnification of the Church which are set forth on this form and incorporated herein by reference, by which I am releasing and/or holding harmless the Church, its staff, and volunteers from any liability incurred by the Church arising out of any Church-sponsored activity in which he/she participates. 3. Medical: I also give my consent, approval, and authorization for Church staff or other adult supervisors to authorize emergency medical treatment if reasonably deemed necessary by them.
 
LEGAL RELEASE OF LIABILITY & INDEMNIFICATION

The Parent hereby:
a. Agrees to review all the information provided by the Church concerning any Church sponsored activity, and agrees to the precautions planned for the safety and care of the participants;
b. Acknowledges that, notwithstanding the exercise of reasonable safety precautions, participation in any Church sponsored activity involves certain actual and potential risks(s) of loss;
c. Agrees that should the participant be asked to return home due to disciplinary action, medical reasons, or otherwise, it shall be the Parent’s responsibility to provide transportation home and to cover all associated and related expenses;
d. Releases the Church from all liability for any loss incurred by the participant or by the Parent arising out of or related to any Church sponsored activity, except for loss due to the Church’s willful misconduct, and
e. Agrees to indemnify and hold the Church harmless from any liability for loss incurred by the Church (1) as the result of injuries to the participant or (2) due to the acts of the participant, occurring in the context of any Church related activity. As used herein, the term “Loss” means personal injury, sickness, loss of life, or damage to or loss of property, real or personal; “Church” means Locust Valley Chapel, Coopersburg, PA, its Elders, Trustees, Deacons, Pastors, and staff, its leadership supervisors, volunteers, and members; and “Parent” means the parent(s) or legal guardian(s) of the participant identified above. Parent represents, warrants, and agrees that by signing this form the Parent has full legal authority to do so; that the Parent has legal custody of the participant; that the approval and agreement of any other parent or guardians has been obtained by Parent, and that the undertakings herein shall be binding upon the Parent, any other Parent or guardian, the participant, and their respective heirs, personal representatives, and assigns.
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Description

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